The purpose of this proposed career development award is to support Dr. Ayse P. Gurses, a human factors engineer, in establishing a research program that seeks to improve patient safety during transitions of care and handoffs. This award will facilitate Dr. Gurses's acquisition of additional skills and competencies in the areas of outcomes research, advanced research methods, and advanced statistical methods that are necessary for accomplishing her career goals. Moreover, the award will provide Dr. Gurses the opportunity to get mentoring from leading researchers who also have a strong track record of mentoring research scientists. The Johns Hopkins University offers an ideal environment for the proposed work, particularly because of the strong Schools of Medicine and Public Health and the strong focus on patient safety research. Increasing specialization in medicine, coupled with limited resources, has led to an increase in the number of care transitions. Unfortunately, care transitions can pose significant risks to patient safety and result in poor clinical and financial outcomes if not managed effectively. Dr. Gurses's long-term goal is to develop a care transitions improvement program that can be implemented nationally and internationally to improve patient safety. The overall objective of the proposed study is to identify the potential risks for post-operative cardiac surgery patients' safety in care transitions, and to develop methods and tools to reduce these risks. We will focus on cardiac surgery patients because of the complexity and severity of their illnesses and their needs for receiving medical care from various practitioners in multiple settings. We will focus on two processes of care: medication information management and the medical record interactions. To accomplish the overall study objective, we will first identify hazards (anything that has the potential to cause failure) that threaten post-operative cardiac surgery patients' safety in transitions of care (a) between different units in a hospital; (b) from hospital to home and to outpatient clinics. We will use both prospective and retrospective hazard identification methods. We will then conduct a prospective risk assessment of the identified hazards using the Health Care Failures Modes and Effects Analysis (HFMEA). We will conduct a separate HFMEA for each care process (e.g., medication information management); at each point of care transition (e.g., transfer from ICU to general floor). Finally, we will develop a novel; risk-analysis-informed intervention bundle and pilot test its impact on the safety of care transitions for post-operative cardiac surgery patients and on the care providers. Ineffective and poor transitions of care are a major threat to patient safety. This is especially true for patients who had cardiac surgery because of the complexity and severity of their illnesses and their needs for receiving medical care from various practitioners in multiple settings. In this study, we will identify the factors that lead to poor care transitions and unsafe care for post-operative cardiac surgery patients. We will then develop and pilot test tools and strategies to improve care transitions and the safety of post-operative cardiac surgery patients. These tools and strategies can potentially be used to improve the safety of care transitions for other patient populations in the future.